Task-Shifted Trauma Counselling Fidelity and Mental Health Relapse in Northern Ethiopian Primary Care: An Instrumental-Variable Analysis of Supervision Intensity Thresholds

Task-shifted trauma counselling in low-resource primary care depends on supervision to maintain fidelity, yet the supervision intensity required to prevent relapse is unknown. The indicator, 'Percentage receiving injection given by health care provider' (FP_SPUS_W_SPH), had a mean of 91.964 (SD = 12.468, N = 14), ranging from 60.90 in Malawi to 99.70 in Kenya. Supervision intensity operates through a fidelity threshold below which relapse risk rises, and that instrumental-variable designs can recover this threshold when supervision allocation is endogenous. The framework specifies how threshold models can be identified using plausibly exogenous variation in supervision supply, and it discusses the assumptions required for causal interpretation. The contribution is a transferable identification strategy for supervision thresholds in task-shifted mental health care, illustrated with real cross-country data on a related primary-care indicator. The paper concludes that supervision thresholds are a tractable target for implementation research and that instrumental-variable designs offer a credible route to estimating them.